Thank you for choosing ALTITUDE PHYSICAL THERAPY, a Member of the P3 Network - PT-MD Kinect LLC & Partners in Health Healing Center

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3 Thank you for choosing ALTITUDE PHYSICAL THERAPY, a Member of the P3 Network - PT-MD Kinect LLC & Partners in Health Healing Center Below is some information you may find helpful regarding your benefits and your responsibilities: o Your services are being billed under the P3 contract. This means that billing will reflect the following provider and network facility names. o PT-MD Kinect LLC o Matthew D. Pouliot DO o Partners in Health Healing Center o Heather L. Fliege MD o Your insurance company told us they cover visits per calendar, plan or policy year. If you have received physical therapy earlier in the year, those visits will count toward this maximum. Remember, your prescription from your doctor is a suggestion, however insurance co-dictates the total number of visits allowed depending upon your injury and expected progress. If you have any questions about your insurance coverage or your policy, please contact your insurance company. Importance of Paperwork and Re-evaluations- Evaluations, re-evaluations, special tests, and thorough documentation allows us to identify the best treatment to assist you in a complete recovery. These reevaluations and progress surveys are used to make adjustments in your treatment program to assure you of quality care that results in a quick and complete recovery. Your assistance in filling out these forms and progress surveys is appreciated. Scheduling Please schedule as much in advance as possible so we can provide you with convenient appointment times. Also, try to schedule with the same therapist, but not more than two therapists if necessary, to allow consistency with your treatment, so we may give you quality care. Please be aware that we are here to serve you, however if you will not be able to be here, kindly give us a 24 hour notice if you have to cancel your appointment. All missed appointments or no shows will be charged a $45 fee to the patient. We have reserved an allotted time for you which is now lost. Billing You have signed our Financial Policy that will allow the P3 network to bill your insurance company. Any billing questions need to be directed to the PT-MD Kinect LLC and Partners in Health Healing Center (P3 Network) billing company: Flatirons Practice Management (303) Payment for co-pays, deductibles, and supplies are due at the time of service. Payment plans are available and can be set up with a billing representative. Only written financial agreements will be honored, no verbal or implied agreements accepted. You are responsible for any portion of your bill which is denied or not paid by your insurance. This includes but is not limited to; deductible, coinsurance and co-pays. Insurance has days to process any claims, which means we may not know what your portion of the bill may be until the claim has been processed. Supply Policy Various supplies may be very helpful in speeding your recovery. Supplies must be paid for the same day they are taken home. If you need to return a supply, we ask that you do so within 10 business days, with the original packaging and in new resalable condition. You must have a receipt also. No returns on special order or custom items. Print patient name: Patient signature: Date: If you have any questions, please do not hesitate to ask us! [Type text]

4 Patient Name Date Are you presently working Yes No Date of next physician s visit: / / Date of injury/onset: / / Have you ever had these symptoms before? Yes No Check which apply to your current condition: Work- related injury Recurrence of previous injury Athletic/recreational injury Motor vehicle accident Injury related to lifting Injury related to falling Cause unknown Other Have you had a related surgery? Yes No Do you have, or have you had any of the following? Yes No Yes No Diabetes Allergies to Aspirin Chest Pain/Angina Allergies to Heat High Blood Pressure Allergies/Poor tolerances to Cold Heart Disease Other Allergies Heart Attack Hernia Heart Palpitations Seizures Pacemaker Metal Implants Headaches Dizziness/Fainting Kidney Problems Recent Fractures Are you pregnant? Surgeries Cancer Skin Abnormalities Osteoporosis Sexual Dysfunction Bowel/Bladder Abnormalities Nausea/Vomiting Urine Leakage Ringing in your ears Asthma/Breathing Difficulties Rheumatoid Arthritis Liver/Gallbladder Problems Special Diet Guidelines Smoking Hypoglycemia Other Stroke/CVA If yes on any of the above, please briefly explain and give approximate date Is there any other information regarding your past medical history that we should know about? Are you presently taking medication? Yes No If yes, please list what medication and for what condition: Page 1 of 2

5 In the rare instance of an emergency, whom should we contact? Name Phone Do you participate in any sports, exercise programs or actives ona regular basis? Yes No If yes, please list Please indicate below where your symptoms are located. Key: Numbness ========= Pins & Needles ooooooooo Burning Pain xxxxxxxxxxx Stabbing Pain //////////// If you are having pain please rate the intensity of your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible Patient s Signature Signature of Guardian if patient is a minor Therapist s Signature Date Date Date Page 2 of 2

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